- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $4,073.80 / $28,183.83
| Professional | | $1,862.09 | $4,073.80 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,623.41 / $6,165.95 / $6,165.95
| Professional | | $5,623.41 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $3,801.89 / $7,079.46
| Facility | | $3,801.89 | $3,801.89 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $7,585.78 / $10,964.78
| Professional | | $3,801.89 | $7,585.78 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $6,918.31 / $27,542.29
| Facility | | $4,073.80 | $6,918.31 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,801.89 / $6,309.57
| Professional | | $2,137.96 | $3,801.89 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6,918.31 / $7,079.46 / $16,982.44
| Professional | | $6,918.31 | $7,079.46 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8,912.51 / $15,848.93 / $16,982.44
| Professional | | $8,912.51 | $15,848.93 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $4,365.16 / $6,606.93
| Facility | | $3,801.89 | $4,365.16 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $3,162.28 / $5,011.87
| Professional | | $2,290.87 | $3,162.28 | $5,011.87 |